Individual Intake Form

GENERAL
Name (required): Date of birth
Address:
City: State: ZIP:
Home phone: May I leave a message?  Yes No
Work/Cell phone: May I leave a message?  Yes No
Email: May I contact you via email?  Yes No
Employer/school: Occupation/studying
Emergency contact: Phone: Relationship:
Educational background:
Learning disabilities:
Religious upbringing:
Present affiliation/identification (if any):
Current living situation:
Reason for seeking counseling/therapy at this time:
What do you hope to achieve with therapy?

MEDICAL HISTORY
General health:
Are you now under a physician’s care?  Yes No
If yes, reason for care:
Physician’s name: Telephone:
Medications:
Reason for medication:
Last medical examination:
Have you ever been hospitalized for a physical illness?  Yes No
Describe:

Have you ever been hospitalized for a mental illness?  Yes No
Describe:

Have you ever considered or attempted suicide?  Yes No
If yes, please explain:

Have you ever been in a drug, alcohol or other treatment program?  Yes No
If yes, please provide details:

Do you currently drink alcohol?  Yes No
How much/how often:
Do you currently use recreational drugs?  Yes No
How much/how often:
Do you feel you have a problem with alcohol or drugs?  Yes No
Previous therapy/counseling:  Yes No
If yes, describe reason, duration and outcome:

Please check any of the following struggles that pertain to you:
 Anxiety Sexual Problems Finances Self-Control Work/Stress
 Depression Suicidal Thoughts Drug/Alcohol Use Unhappiness
 Health Problems Fears/Phobias Separation/Divorce Career Choices
 Insomnia Cutting/Self-Mutilation Eating Disorders
 Relationships Anger Religious Matters Thought Patterns

WORK HISTORY
Occupation: How long?
If presently unemployed, describe situation:

Hobbies/avocations:

FAMILY INFORMATION
Parents and step-parents (indicate under “age” if deceased)
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation

Siblings and step-siblings (indicate under “age” if deceased)
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation

Do any of your relatives have a history of mental illness?  Yes No
If yes, please explain:

Significant partner status (please select):
 Single Engaged Married Divorced Separated Living together Remarried Widowed Other
Name of significant partner:
Children from this relationship:
Name Gender Age
Name Gender Age
Name Gender Age
Name Gender Age
Children from previous relationship:
Name Gender Age
Name Gender Age
Name Gender Age
Name Gender Age